Intervention development of a brief messaging intervention for a randomised controlled trial to improve diabetes treatment adherence in sub-Saharan Africa

Designing Mobile Phone Text Messages Using the Behavior Change Wheel Framework to Influence Food Literacy in Adults With Type 2 Diabetes in Kenya: Protocol for a Systematic Development Study

BACKGROUND

The worldwide prevalence of type 2 diabetes (T2D) has increased in the past decade, and it is projected to increase by 126% by 2045 in Africa. At the same time, mobile phone use has increased in Africa, providing a potential for innovative mobile health interventions to support diabetes care.

OBJECTIVE

This study aimed to apply the Behavior Change Wheel (BCW) framework to develop text messages to influence food literacy in adults with T2D in urban Kenya.

METHODS

The 8 steps of the BCW framework guided the development of text messages: (1) Define the problem in behavioral terms; (2) select target behaviors; (3) specify the target behaviors based on who needs to perform the behaviors, what needs to change, and when, where, how often, and with whom; (4) identify what needs to change; (5) identify intervention functions; (6) select policy categories; (7) select behavior change techniques (BCTs); and (8) select the mode of delivery. Recent exploratory studies in Kenya and other low- and middle-income countries provided information that was used to contextualize the intervention.

RESULTS

In step 1, the behavioral problem was defined as unhealthy dietary patterns among adults with T2D. In step 2, based on a qualitative study in the target population, the target behavior was selected to be evaluation of reliable sources of information, and selection and preparation of healthy food. In step 3, unhealthy dietary patterns were selected. In step 4, 10 domains of the Theoretical Domains Framework were identified, and in step 5, 5 intervention functions were linked to the domains and unhealthy dietary patterns were specified. In step 6, communication and regulations were identified as policy categories, while in step 7, 9 BCTs were selected from the Behavior Change Technique Taxonomy version 1. In step 8, the most suitable mode of delivery was determined to be mobile text messages. A total of 36 mobile text messages were developed based on the 9 BCTs.

CONCLUSIONS

This study shows the step-by-step application of the BCW framework to develop mobile text messages to influence food literacy in adults with T2D.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/48271.

Integrating intimate partner violence prevention content into a digital parenting chatbot intervention during COVID-19: Intervention development and remote data collection

BACKGROUND

Intimate partner violence (IPV) is a serious public health issue which experienced a sharp incline during the onset of COVID-19. Increases in other forms of violence, such as violence against children (VAC), have also been linked to the pandemic, and there have been calls for greater prevention efforts that tackle both forms of violence concurrently. The COVID-19 crisis has highlighted the urgent need for evidence-based and scalable violence prevention interventions that target multiple forms of family violence. Parenting programmes have shown promising results in preventing various forms of family violence, including IPV and VAC, and have recently experienced an expansion in delivery, with digital intervention formats growing. This paper describes the development and evaluation of the IPV prevention content designed and integrated into ParentText, a chatbot parenting intervention adapted from Parenting for Lifelong Health programmes.

METHODS

The ParentText IPV prevention content was developed using the Six Steps in Quality Intervention Development (6SQuID) framework. This involved targeted literature searches for key studies to identify causal factors associated with IPV and determining those with greatest scope for change. Findings were used to develop the intervention content and theory of change. Consultations were held with academic researchers (n = 5), practitioners (n = 5), and local community organisations (n = 7), who reviewed the content. A formative evaluation was conducted with parents in relationships (n = 96) in Jamaica to better understand patterns in user engagement with the intervention and identify strategies to further improve engagement.

RESULTS

Using the 6SQuID model, five topics on IPV prevention were integrated into the ParentText chatbot. Text-messages covering each topic, including additional materials such as cartoons and videos, were also developed. The formative evaluation revealed an average user-engagement length of 14 days, 0.50 chatbot interactions per day, and over half of participants selected to view additional relationship content.

CONCLUSIONS

This article provides a unique contribution as the first to integrate IPV prevention content into a remotely delivered, digital parenting intervention for low-resource settings. The findings from this research and formative evaluation shed light on the promising potential of chatbots as scalable and accessible forms of violence prevention, targeting multiple types of family violence.

Prevalence and sociodemographic correlates of diabetes among adults in Namibia and South Africa

OBJECTIVE

The aims of this study were to understand the prevalence and sociodemographic characteristics associated with diabetes among adults in Namibia and South Africa.

METHODS

Data from the Demographic and Health Survey for Namibia (2013) and South Africa (2016) were analyzed. The dependent variable, diabetes, was defined using lab values for blood glucose≥ 126 for Namibia, and hemoglobin A1c (HbA1c) ≥ 6.5% for South Africa. Logistic regression was used to identify independent correlates of diabetes for each country. Demographic (age, sex, geographic location, number of children), economic (wealth index, education level), and cultural (religion - Namibia, ethnicity - South Africa) factors were added in blocks to the models.

RESULTS

In Namibia, 4.6% had diabetes based on blood glucose, and 14.6% had diabetes based on HbA1c in South Africa. In Namibia, after adjustment, higher wealth was independently associated with diabetes (OR:1.67; 95% CI: 1.11, 2.50). In South Africa, after adjustment, those who were older (OR: 1.06; 95% CI: 1.04, 1.07), female (OR: 1.25; 95% CI: 1.03, 1.52), lived in a rural area (OR: 1.54; 95% CI: 1.20, 1.96), and Black (OR: 2.27; 95% CI: 1.17, 4.42) or Other (OR: 5.74; 95% CI: 2.50, 13.20) compared to White, had increased odds of diabetes.

CONCLUSIONS

Prevalence of diabetes is high in South Africa and relatively low in Namibia using reliable laboratory diagnostic indices. Strategies to address the rising burden of non-communicable diseases like diabetes are needed in sub-Saharan Africa.

Do community-based active case-finding interventions have indirect impacts on wider TB case detection and determinants of subsequent TB testing behaviour? A systematic review

Community-based active case-finding (ACF) may have important impacts on routine TB case-detection and subsequent patient-initiated diagnosis pathways, contributing "indirectly" to infectious diseases prevention and care. We investigated the impact of ACF beyond directly diagnosed patients for TB, using routine case-notification rate (CNR) ratios as a measure of indirect effect. We systematically searched for publications 01-Jan-1980 to 13-Apr-2020 reporting on community-based ACF interventions compared to a comparison group, together with review of linked manuscripts reporting knowledge, attitudes, and practices (KAP) outcomes or qualitative data on TB testing behaviour. We calculated CNR ratios of routine case-notifications (i.e. excluding cases identified directly through ACF) and compared proxy behavioural outcomes for both ACF and comparator communities. Full text manuscripts from 988 of 23,883 abstracts were screened for inclusion; 36 were eligible. Of these, 12 reported routine notification rates separately from ACF intervention-attributed rates, and one reported any proxy behavioural outcomes. Two further studies were identified from screening 1121 abstracts for linked KAP/qualitative manuscripts. 8/12 case-notification studies were considered at critical or serious risk of bias. 8/11 non-randomised studies reported bacteriologically-confirmed CNR ratios between 0.47 (95% CI:0.41-0.53) and 0.96 (95% CI:0.94-0.97), with 7/11 reporting all-form CNR ratios between 0.96 (95% CI:0.88-1.05) and 1.09 (95% CI:1.02-1.16). One high-quality randomised-controlled trial reported a ratio of 1.14 (95% CI 0.91-1.43). KAP/qualitative manuscripts provided insufficient evidence to establish the impact of ACF on subsequent TB testing behaviour. ACF interventions with routine CNR ratios >1 suggest an indirect effect on wider TB case-detection, potentially due to impact on subsequent TB testing behaviour through follow-up after a negative ACF test or increased TB knowledge. However, data on this type of impact are rarely collected. Evaluation of routine case-notification, testing and proxy behavioural outcomes in intervention and comparator communities should be included as standard methodology in future ACF campaign study designs.

Digital messaging to support control for type 2 diabetes (StAR2D): a multicentre randomised controlled trial

Background

Failure to take medicines for diabetes as prescribed contributes to poor outcomes from the condition. Mobile phones are ubiquitous and short message service (SMS) texts have shown promise as a low-cost intervention. We tested the effectiveness of SMS-text messaging in improving outcomes in adults with type 2 diabetes.

Methods

StAR2D was a 12-month two-arm randomised trial of SMS-text messaging and usual care in Cape Town, South Africa and Lilongwe, Malawi. Messages used behaviour change theory and were developed with patients and staff. The intervention group received four messages each week. The primary outcome was change in HbA1c. Secondary outcomes were the proportion of patients who collected > 80% medication and changes in systolic blood pressure, lipids, cardiovascular risk, and the proportion of the participants reaching treatment goals.

Results

The trial took place between 1 October, 2016 and 1 October 2018, 1186 participants were randomised to intervention (593) and control (593) groups. 91% of participants completed follow-up. There was a reduction in HbA1c (DCCT) in both groups but not in mean change (95% CI) between groups (− 0.08% (− 0.31 to 0.16) (IFCC − 0.82 mmol/mol (− 3.44 to 1.79). There was a small but not significant increase in the proportions of participants likely to have collected 80% or more of medication (Relative risk 1.11 (0.84 to 1.47; P = 0.47). There was a significant difference between groups in change in systolic blood pressure from baseline of 3.46 mmHg (1.48 to 5.44, P = 0.001) in favour of the intervention group. The between group difference in change in 10-year risk of coronary heart disease was − 0.71% (− 1.46 to 0.04, P = 0.064). The proportion of participants meeting treatment goals in the intervention group was 36.0% and in the control group 26.8% (Relative risk 1.36 (1.13 to 1.63, P = 0.001). Participants reported many challenges to adherence despite finding messages acceptable and useful.

Conclusions

Whilst SMS text messages do not lead to improved glycaemia in these low-resource settings there appeared to be an impact on blood pressure and achievement of treatment goals but the mechanisms for this are unclear. Text messages alone, may be unsuccessful unless accompanied by health system strengthening and other forms of self-management support for type 2 diabetes.

Trial registration

Trial registration: ISRCTN, ISRCTN70768808. Registered 1 July 2015, http://www.isrctn.com/I ISRCTN70768808.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11874-7.

Process evaluation of a brief messaging intervention to improve diabetes treatment adherence in sub-Saharan Africa

Background

The SMS text Adherence suppoRt for people with type 2 diabetes (StAR2D) intervention is a pragmatic randomised controlled trial, testing the effectiveness of brief text messaging for improving clinical outcomes and medication adherence. The intervention did not impact glycaemic control. We conducted a pre-and post-trial process evaluation alongside the StAR2D study in Malawi and South Africa, exploring the experiences and perceptions of patient participants, to better understand potential underlying reasons for the trial outcomes.

Methods

We employed a qualitative research design, including conducting semi structured in-depth interviews and focus groups at both trial sites. Purposive sampling was used to ensure representation of a wide range of patients with type 2 diabetes with regards to age, gender, ethnicity, language, and duration of diabetes. We interviewed the same participants at baseline and at the end of the trial. We used within-case and across-case thematic analysis to identify key themes.

Results

Brief messages delivered by text were acceptable and useful for addressing informational and support needs for participants. Some participants reported behaviour changes because of the text reminders and advice on a healthy lifestyle. Both participating in the trial and the messages were experienced as a source of support, caring, and motivation. Participants’ ability to act on the messages was limited. A common theme was frustration over the lack of ability to effectively control one’s blood glucose level. They reported a range of routinised, partial diabetes care adherence behaviours, shaped by complex and interacting individual, social, and health service factors. Participant responses and intervention impact were similar across sites, despite differences in health services.

Conclusion

This process evaluation provided context and insight into the factors influencing participants’ engagement with the text messaging intervention. The complex context in which patients take their diabetes medication, may explain in part, why brief text messaging may have been insufficient to bring about changes in health outcomes. The scale of need for self-management and health service support, suggests that health system strengthening, and other forms of self-management support should accompany digital communication interventions. (Current Controlled Trials ISRCTN70768808, registered 03/08/2015.)

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11552-8.

Systematic Review and Meta-Analysis of the Diagnostic Accuracy of Mobile-Linked Point-of-Care Diagnostics in Sub-Saharan Africa

Mobile health devices are emerging applications that could help deliver point-of-care (POC) diagnosis, particularly in settings with limited laboratory infrastructure, such as Sub-Saharan Africa (SSA). The advent of Severe acute respiratory syndrome coronavirus 2 has resulted in an increased deployment and use of mHealth-linked POC diagnostics in SSA. We performed a systematic review and meta-analysis to evaluate the accuracy of mobile-linked point-of-care diagnostics in SSA. Our systematic review and meta-analysis were guided by the Preferred Reporting Items requirements for Systematic Reviews and Meta-Analysis. We exhaustively searched PubMed, Science Direct, Google Scholar, MEDLINE, and CINAHL with full text via EBSCOhost databases, from mHealth inception to March 2021. The statistical analyses were conducted using OpenMeta-Analyst software. All 11 included studies were considered for the meta-analysis. The included studies focused on malaria infections, Schistosoma haematobium, Schistosoma mansoni, soil-transmitted helminths, and Trichuris trichiura. The pooled summary of sensitivity and specificity estimates were moderate compared to those of the reference representing the gold standard. The overall pooled estimates of sensitivity, specificity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio of mobile-linked POC diagnostic devices were as follows: 0.499 (95% CI: 0.458–0.541), 0.535 (95% CI: 0.401–0.663), 0.952 (95% CI: 0.60–1.324), 1.381 (95% CI: 0.391–4.879), and 0.944 (95% CI: 0.579–1.538), respectively. Evidence shows that the diagnostic accuracy of mobile-linked POC diagnostics in detecting infections in SSA is presently moderate. Future research is recommended to evaluate mHealth devices’ diagnostic potential using devices with excellent sensitivities and specificities for diagnosing diseases in this setting.